Nokea
Which statement made by the parent of a child newly diagnosed with sickle cell anemia indicates a need for more teaching?
- A. We are going to the mountains for our vacation this year.'
- B. It's a good thing she likes to drink juices.'
- C. If she needs something for pain, I will give her baby acetaminophen.'
- D. I will make sure that she doesn't get chilled when it is cold outside.'
Correct Answer: A
Rationale: High altitudes, like mountains, have lower oxygen levels, which can precipitate a sickle cell crisis, indicating a need for more teaching. Drinking juices, using acetaminophen, and avoiding chills are appropriate.
You may also like to solve these questions
Which sign/symptom should the nurse expect to assess in the client diagnosed with hemophilia A?
- A. Epistaxis.
- B. Petechiae.
- C. Subcutaneous emphysema.
- D. Intermittent claudication.
Correct Answer: A
Rationale: Hemophilia A causes bleeding; epistaxis (A) is common. Petechiae (B) indicate thrombocytopenia, emphysema (C) is unrelated, and claudication (D) is vascular.
The nurse is administering vesicant chemotherapy medications such as doxorubicin hydrochloride to clients. Which nursing actions should the nurse implement to prevent extravasation?
- A. Give through an IV catheter in a large peripheral vein if infusing in less than 60 minutes.
- B. Check patency every 5 to 10 minutes during infusion and ask about IV site discomfort.
- C. Check the IV pump and alarm for indications of an infiltration of the medication.
- D. Check for blood return in a central venous catheter prior to administration of the vesicant.
- E. Use small-gauged syringes with small barrels when flushing any access devices with saline.
Correct Answer: A, B, D
Rationale: A peripheral IV catheter may be used for a vesicant if administration time is less than 60 minutes, a large vein is used, and there is careful monitoring of the IV site. B. Checking for patency and asking about discomfort at the IV site will help prevent an infiltration. C. IV pumps and alarms cannot be relied upon to detect extravasation because infiltration usually does not cause sufficient pressure to trigger an alarm. D. Checking for blood return in the central venous catheter prior to administration will help ensure that the medication is being administered into a vessel and not into tissues. E. Small-gauge syringes with small barrels produce high pressures and may cause injury to the blood vessel or may damage a central line catheter and should not be used.
The client has a hematocrit of 22.3% and a hemoglobin of 7.7 g/dL. The HCP has ordered two (2) units of packed red blood cells to be transfused. Which interventions should the nurse implement? Select all that apply.
- A. Obtain a signed consent.
- B. Initiate a 22-gauge IV.
- C. Assess the client’s lungs.
- D. Check for allergies.
- E. Hang a keep-open IV of D5W.
Correct Answer: A,C,D
Rationale: Consent (A), lung assessment (C), and allergy checks (D) ensure safe transfusion. A 22-gauge IV (B) is too small (18-gauge preferred), and D5W (E) is incompatible (use NS).
The client diagnosed with non-Hodgkin's lymphoma is scheduled for a lymphangiogram. Which information should the nurse teach?
- A. The scan will identify any malignancy in the vascular system.
- B. Radiopaque dye will be injected between the toes.
- C. The test will be done similar to a cardiac angiogram.
- D. The test will be completed in about five (5) minutes.
Correct Answer: B
Rationale: Lymphangiogram involves dye injection between toes (B) to visualize lymphatics. It’s not vascular (A), unlike cardiac angiogram (C), and takes longer than 5 minutes (D).
Which test is considered diagnostic for Hodgkin's lymphoma?
- A. A magnetic resonance image (MRI) of the chest.
- B. A computed tomography (CT) scan of the cervical area.
- C. An erythrocyte sedimentation rate (ESR).
- D. A biopsy of the cervical lymph nodes.
Correct Answer: D
Rationale: Lymph node biopsy (D) diagnoses Hodgkin’s via Reed-Sternberg cells. MRI/CT (A, B) stage disease, ESR (C) is nonspecific.